Suicide Prevention Strategy: Government Pledges £1.5m Funding

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Bereavement, Children, economy, men, mental health issues, prevention, self-harm, suicide, support, women

Suicide Prevention Strategy: Government Pledges £1.5m Funding

The government has promised to pump £1.5m into research exploring how to prevent suicides among those most at risk of taking their own lives.

The pledge comes as ministers unveiled a new suicide prevention strategy that is aiming to cut the suicide rate and provide more support to bereaved families

Funding will be used to look at how suicides can be reduced among people with a history of self-harm.

Researchers will also focus on cutting suicides among children and young people and exploring how and why suicidal people use the internet.

Launching the new strategy to coincide with World Suicide Prevention Day, Care Services Minister Norman Lamb said: “One death to suicide is one too many – we want to make suicide prevention everyone’s business.

“Over the last 10 years there has been real progress in reducing the suicide rate, but it is still the case that someone takes their own life every two hours in England.

“We want to reduce suicides by better supporting those most at risk and providing information for those affected by a loved one’s suicide.”

Around 4,200 people in England took their own lives in 2010 and suicide continues to be a public health issue – especially in the current period of economic uncertainty, the Department of Health said.

The suicide rate is highest amongst men aged between 35-49, while men are three times more likely than women to take their own life, according to statistics.

The new strategy, which is being backed by charity the Samaritans, is the first in more than 10 years.

Under the fresh approach, the government will work with the UK Council for Child Internet Safety to help parents ensure their children are not accessing harmful suicide-related websites.

It will also aim to reduce opportunities for suicide by ensuring prisons and mental health facilities keep people safer.

Improved support for high-risk groups – such as those with mental health problems and people who self-harm – and well as those bereaved or affected by suicide will also be offered.

Chair of the National Suicide Prevention Strategy Advisory Group, Professor Louis Appleby said: “Suicide does not have one cause – many factors combine to produce an individual tragedy.

“Prevention too must be broad – communities, families and front-line services all have a vital role.

“The new strategy will renew the drive to lower the suicide rate in England.”

Around 50 national organisations from the voluntary, statutory and private sectors have also agreed to work together to tackle suicide by sharing best practice and providing support to those in need.

Samaritans chief executive Catherine Johnstone said: “We are encouraged that the government has taken this step in continuing to acknowledge the importance of suicide prevention.

“We firmly believe that suicide can be prevented by making sure people get support when they need it, how they need it and where they need it.

“This means we all have to try harder to reach people who may not now be talking to anyone about the problems they face.”

Indiana prosecuting Chinese woman for suicide attempt that killed her foetus

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Bereavement, miscarriage, pregnancy, suicide

Indiana prosecuting Chinese woman for suicide attempt that killed her foetus

When her baby Angel died in her arms at 1.30am on 3 January 2011, Bei Bei Shuai was so distraught she was instantly transferred to the mental health wing of the Methodist hospital in Indianapolis. Grief stricken and under heavy sedation, she was unaware that within half an hour of her baby’s death a detective from the city’s homicide branch had arrived at the maternity ward and had begun asking questions.

While Shuai was embarking on a journey into bereavement that continues to this day, the Indianapolis authorities were also setting out, albeit along a very different path. On 14 March last year Shuai was arrested and taken into custody in the high-security Marion County prison, where she was held for the next 435 days, charged with murdering her foetus and attempted feticide. If convicted of the murder count she faces a sentence of 45 years to life.

Bei Bei Shuai is at the sharp end of the creeping criminalisation of pregnancy across America. Women who lose their unborn babies – whether in cases of maternal drug addiction or in Shuai’s case a failed suicide attempt – are increasingly finding themselves accused of murder.

Speaking publicly for the first time, Shuai told the Guardian she is determined to defend herself as she prepares for a murder trial scheduled for December. “I have a strong desire to stay in America,” she said, three days after she had been released from jail on $50,000 bail. “I want to stay and fight this case. I have the best legal team, and I’m not afraid anymore to face the charges.”

On 23 December 2010 Shuai became so depressed after she had been abandoned by her boyfriend – a married Chinese man who broke his promise to set up a family with her – that she decided to end her life. She consumed rat poison, and after confessing to friends was rushed to the Methodist hospital.

Doctors took steps to save her, but on 31 December there were signs that the baby, then at 33 weeks gestation, was in distress and a Caesarian was performed. On the second day of Angel’s life the baby was found to have a massive brain haemorrhage and on 2 January was taken off life support.

Shuai held Angel for five hours as the baby gradually faded and died. “Why do they want to take my baby away?” she kept asking, in between bouts of fainting. Shuai begged for her own life to be taken so that her child’s might be spared.

‘No one wins from the criminalisation of pregnant women’

“There is no doubt that Shuai was suffering from a severe mental illness,” her defence lawyer Linda Pence said. She first met the defendant when she was in the mental wing, a few days after Angel died. “I personally observed a very depressed woman, a grief-stricken individual.”

That is not how the prosecutor saw it. For the first time in Indiana‘s 196-year history, the state has applied felony charges against a woman that hold Shuai criminally liable for the outcome of her pregnancy. Earlier this month the Indiana supreme court declined to hear the case, rendering a 3 December murder trial almost inevitable.

Lawyers and women’s advocates in Indiana were astonished by the prosecution’s hard line. To attempt to take one’s own life is not a crime in Indiana, so the decision to charge a pregnant woman appeared to be creating a double standard.

The feticide law, introduced in Indiana in 1979, was designed with violent third parties in mind: abusive boyfriends or husbands who attacked their pregnant partners, causing them to lose their unborn babies. It was enhanced to carry a maximum sentence of 20 years in 2007 after a bank robbery in which a pregnant woman was shot in the stomach, killing her fetus but leaving her alive.

“From a legal standpoint, this case is absolutely frightening,” said Pence, who has set up a website and fighting fund to support Shuai’s defence.

Pence fears that Shuai’s prosecution could set a precedent that will catch others in its trap. In the future, could women who smoke or drink during pregnancy and suffer a miscarriage be prosecuted for murder, or women with HIV who pass it on to their child in the womb? “No one wins from the criminalisation of pregnant women – all this will do is persuade women to flee the state, avoid treatment or have an abortion,” Pence said.

‘I knew America as the best country in the world’

Shuai sees the threat now facing her from a different perspective – as the obliteration of her American dream. She was raised as a single child in Shanghai by parents she described as loving and caring. She graduated from Shanghai university as an accountant, worked for a year in a Chinese government department and then came to the US about 10 years ago as a legal immigrant with her then-husband, who was offered a job in Indianapolis as a mechanical engineer.

Shuai said she was delighted to come to the US. “I knew America as the best country in the world, with the best education system. People get more freedom. I really wanted to see what it was like.”

She found the initial arrival in her Indiana town – a tiny one compared to Shanghai – a bit of a culture shock, but over time she said she came to appreciate it more and more: “Seeing all the natural trees and flowers, the fresh air.”

She was full of dreams – the dream of continuing her studies, the dream of forming her own family, of owning a house and car. “Everybody tells me that they have their American dream, trying to make their life better. People tell me that all the time, and I am the same, I am one of them,” she said.

The dreams didn’t work out so easily. She couldn’t afford to go back to college, so instead studied under her own steam using the local library. Her marriage collapsed, and then when she did finally become pregnant it was with a married man.

When he abandoned her, he left Shuai on her hands and knees in a parking lot as he drove away.

Shuai is not allowed to discuss the events that led up to her suicide attempt, as that might prejudice her trial. But she can talk about the deep sense of shame she felt when she was arrested for killing her foetus.

“I remember the day I had to turn myself in. I felt hopeless and ashamed, for myself and my parents. I had never worn handcuffs before – when they put the cuffs on me it chilled me to my bones.”

Now released, her hands are free. But she is forced to wear a GPS ankle bracelet that is causing her feet to swell.

Shuai’s lawyers wonder whether it is coincidental that such an aggressive application of a law originally designed to protect pregnant women against violent men should first be applied against a woman who is Chinese. The question is all the more pertinent given the current spat between the US and Chinese governments over the treatment of the blind dissident Chen Guangcheng.

Lynn Paltrow, head of National Advocates for Pregnant Women that is co-counsel in Shuai’s defence, said: “It’s an irony that the US has paid such close attention to violations of human rights in China while at the same time Indiana has absolutely deprived a woman who is a legal immigrant from China of her constitutional human rights.”

Prosecution is determined to push on

The only hope for Shuai to avoid a murder trial is if the prosecutor, Terry Curry, decides to drop the charges. There is little chance of that, given his firm belief that he is following the correct path.

“It’s my job to enforce the criminal code as enacted by our legislature and that’s what our legislature has determined,” he said. Curry pointed to a suicide note that Shuai left the former boyfriend in which she wrote that she was “taking this baby with me”.

“What we allege is that her actions were directed specifically at the unborn child. It’s not that she was trying to take her own life, it was that she was trying to take the life of her foetus,” Curry said.

Curry’s determination to press ahead to trial is matched by Shuai’s determination to fight on. During her year in prison, she has improved her English language skills and now speaks fluently without a translator. Though there were dark times inside, including anxiety attacks and moments of despair, she said she has emerged stronger for it.

“It was a really bad experience. I thought nobody would care about me anymore, that I was a worthless person with no future,” she said. “But I learned a great deal. I learned that my life wasn’t the worst as I thought it was. Everything that has happened has made me think that I am so blessed. I have a second family here, and that gives me hope.”

Shuai kept the truth about her suicide attempt and prosecution for murder from her mother back in Shanghai for almost a year. But a couple of months ago, with the help of her lawyer, she finally confessed.

“My mother was so wonderful and supportive. She told me you don’t need to care about other people’s judgment, as she knew that was what hurt me most. There’s a Chinese saying: ‘A people’s mouth can be sharper than a knife.'”

Despite her ordeal, Shuai insists she remains dogged in her intention to make a life for herself in America, a country that she still regards as the greatest on Earth. But in the last analysis her decision to stay and protest her innocence is made on behalf of only one person.

“I want to prove to my daughter that her mother is not a murderer, and that she has been loved.”

Normal Grief vs Depression In DSM5- Medicalizing Grief

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Bereavement, DSM, Grief, Major Depression

http://www.psychologytoday.com/blog/dsm5-in-distress/201003/normal-grief-vs-depression-in-dsm5

The recently posted draft of DSM5 makes a seemingly small suggestion that would profoundly impact how grief is handled by psychiatry.  It would allow the diagnosis of Major Depression even if the person is grieving immediately after the loss of a loved one. Many people now considered to be experiencing a variation of normal grief would instead get a mental disorder label. For example, take the case of a man whose spouse unexpectedly dies. For two weeks after the death, he feels sad, doesn’t want to go to work, loses his appetite, has trouble sleeping and concentrating. Currently, this is normal grief. The DSM 5 suggestion would have this be major depression.

Undoubtedly, this would be helpful for some people who would receive much needed treatment earlier than would otherwise be the case. But for many others, an inaccurate and unnecessary psychiatric diagnosis could have many harmful effects. Medicalizing normal grief stigmatizes and reduces the normalcy and dignity of the pain, short circuits the expected existential processing of the loss, reduces reliance on the many well established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment.

Grief is an inescapable part of the mammalian experience and a necessary correlate of our ability to attach  so strongly to other people. Though grief is universal, there is no one right way to grieve. Different cultures prescribe a wide variety of different behavioral and emotional reactions and rituals. Psychiatry needs to tread lightly and have compelling reasons before encroaching with its own rituals  on such time honored and usually effective practices.

Within a given culture, normal individuals also vary enormously in the content, symptoms, duration, and impairment of their grief and in their ability to draw consolation and sustenance from others.  There is no bright line separating those who are experiencing loss in their own necessary and particular way from those who will stay stuck in a depression unless they receive specialized psychiatric help.

The numbers on each side of the normal/mental disorder divide are probably very lopsided-most people who grieve do not have a mental disorder. Ever since the dawn of man, humans have had frequent occasions to grieve. Almost all of us come to terms with the loss and the altered conditions of a new life without the benefits of psychiatry-and do just fine on our own. The change in DSM5 would attempt to identify the very small percentage of people who have a complicated grief that goes beyond the average expectable in severity, symptom pattern, and duration – those who would not remit as part of the natural evolution of their grief. But when you use a big shovel to capture a small needle in the haystack, what you mostly get is hay. Any change in the way DSM5 defines grief may gather a very large proportion of false positives who would do better avoiding psychiatric help.

The rationale given by DSM5 for its radical proposal is brief, cryptic, and fails to provide anything like a risk/benefit analysis of  potential effects. DSM5 states that there is no evidence that the depression triggered by the stress of losing a loved one is any different than  depression triggered by other severe stressors (such as job loss or divorce)- thus claiming that there is no justification to withhold the diagnosis of major depression after a loss. This  rationale places the burden of proof in the wrong direction.  DSM5 should make so consequential a change only after a careful and considered evaluation proves with compelling evidence that it will do more good than harm.

Such evidence is simply not available.  The research in this area is interesting but in very early development and we don’t know many essential things. We have no idea how any proposed criteria set would work in the general population.  What percentage of grieving individuals would get the diagnosis (especially once drug companies raise awareness of it)? Among the people who would be diagnosed, we don’t know what percentage truly need psychiatric help, what percentage would do better without it.

Pies and Ziskind (in a recent commentary in Psychiatric Times) have  gone far beyond the meager DSM5 rationale to present the strongest possible case for allowing the diagnosis of Major Depression in grief situations. They cite several lines of argument:

1) There is a clinical need- some individuals have severe, complicated grief that looks just like severe Major Depression and does not get better spontaneously. The longer that diagnosis and treatment are delayed, the greater their suffering, impairment, and risks (eg job loss, injured relationships, lowered treatment response, suicide).

2) The loss of a loved one is not essentially different from the many other serious stressors that abound in life.

3) It is impossible to predict the future misuse of the DSM5 system so we should make decisions based only on the best possible science.

4) The criteria for complicated grief could be tightened to reduce false positives.( They suggest two useful ways described below and I add two others).

5) Education can solve the problem of false positive diagnosis and the risk of providing medicine in milder cases when time, support, and/orpsychotherapy would be more indicated.

The  excellent proposal made by Pies/Ziskind to reduce false positives could be strengthened even further if two additional exclusions were added to the  two(#’s 1and 2 below) that they   suggested . The entire package differentiating grief  from depression would require:

1) An extended duration of one month.

2) A particularly severe presentation that  includes some combination of unreasonable guilt, worthlessness, hopelessness, self loathing, anhedonia, a focus on negative memories of the departed, alienation from others, and inability to be consoled.

3) To recognize the different cultural expressions, the diagnosis of depression would not be made if the person’s grief is within  cultural norms.

4) An exclusion could be added that would take into account the person’s own past experience of grief and its previous outcomes.  If the individual previously had severe grief symptoms, but recovered spontaneously (without going on to a major depression), this would suggest they are now grieving their own way and do not require diagnosis or treatment.

DSM5 has made many poorly thought through suggestions that can be fairly easily dismissed. Though I continue to disagree with the  Pies/Ziskind proposal, it is reasonable and deserves serious consideration. Here are the opposing points:

1) Re clinical need: In appropriate cases displaying  clinically significant impairment, distress, or risk, the diagnosis Depression Not Otherwise Specified covers their false negative problem.

2) I believe there is a difference between losing a loved one and most other life stressors. This  explains why grief is the universal target of communal healing rituals.  It would be unfortunate forpsychiatry to prematurely roam into problems usually better handled by family and other cultural institutions. Cultural biases would be very hard to surmount in making this diagnosis.

3) My disagreement with Pies and Ziskind is strongest on this point. All decisions for DSM5 should follow the injunction-“First Do No Harm.”Although it is impossible to predict precisely how any DSM5 change will eventually play out once the manual is in general use, that doesn’t reduce DSM’s responsibility for the problems that occur, even if they are unintended. All potential risks have to be thought thru and factored into a thorough risk/benefit analysis.  The argument that we should just go to where the science takes us ignores that the science is (as they point out) not definitive, is subject to different interpretations, and is not readily generalizable from research to real world settings. Once the genie is out of the bottle and DSM5 makes it easy to diagnose depression in grief situations, this could easily become an industry propelled fad diagnosis.

4) The tightened criteria would help reduce, but certainly not eliminate, the grave potential harm caused by the massive misidentification of false positives.
False positives and excessive treatment are not be a problem for skilled and cautious clinicians (like Pies and Zisook), but in the real world most of the prescriptions will be written by primary care physicians who have six minutes with each patient, don’t know the fine points of the criteria sets, and want the fastest solution.

The false positive problem is too unknown and potentially far too large to ignore. At a minimum, there would need to be field trials to determine prevalence, reliability, false positive, and false negative rates. I doubt that DSM5 has the time, money, and skill to pull this off.

5) It would be naïve and unwise to rest our hopes that any educational  program  would reduce over diagnosis and the overprescription of medication in grief situations. To the contrary, most of theeducation would go the other way. The drug companies devote enormous resources to “educating” physicians to be quick on the draw in prescribing medication.

I respect the arguments made by Pies and Ziskind  and believe they  work well when applied by experts like them. My worry is the misuse of even reasonable ideas in the real world  situations where most diagnosis and treatment is done. Loose diagnostic and treating habits could lead to the widespread medicalization of grief well beyond what Pies and Ziskind would themselves recommend. There are two ways of avoiding this. The first is to keep things as they are and not to diagnose Major Depressive Disorder in the first two months after the loss of a loved one.

The second is for DSM5 to allow for the diagnosis of complicated grief but with a  criteria threshold set high and including all four protections against false positives outlined above. As recommended by Pies and Ziskind, there should also be a  physician and public education campaign normalizing normal grief and  sharply delimiting the small group of grievers who need psychiatric
help.

Weighing the pluses and minuses, my call is to keep things as they are and not risk an “epidemic” of psychiatric grief.